Prevention strategies pay off
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While the wellness
movement strives to improve the health of employee groups, it is well
recognized that a handful of diseases are responsible for the majority of
medical costs for most benefit plans. Among the big-ticket items in this
country: treatment of cardiovascular disease, insurance payments for problem
childbirths, direct medical costs for low back pain, treatment of breast
cancer, treatment of asthma, and complications from diabetes that require
hospitalization.
Programs that focus on
prevention and early intervention for these costly conditions have the
potential for huge savings because they go straight to the source of the
largest claims.
Reducing cardiovascular
risk
Preventive measures at
Stratus Computers in Marlboro, Mass., have reduced the need to costly blood
pressure- and lipid-lowering medications through a heart disease
risk-reduction program. "We've saved $50,000 a year in prescription costs
since starting the program," says Tom Harrison, manager of corporate
benefits at Stratus. The savings estimate is based on the value of drugs
that participants avoided as a result of their improvement, and doesn't even
count the cost of hospitalizations, procedures, and work loss that might
have resulted had risk factors not decreased.
The Cardiovascular Risk
Reduction Center of Framingham, Mass., provides training and monitoring for
Stratus employees at high risk for heart disease. Participant attend classes
on such topics as nutrition, exercise, and cholesterol metabolism. Stratus
pays for the three-month program, called HealthMatters, which costs about
$500 per participant. About 120 employees have
completed the program since Stratus Computers began classes in early 1992.
"Seventy-five to eighty percent of participants experience significant
improvement," says Gerald L. Evans, M.D., medical director of the center. He
says that, on average, individuals reduce their total cholesterol levels 15%
to 19%, lower their diastolic blood pressure level 8 to 10 points, and
reduce the percentage of fat in their diet to 20% to 30% by the end of the
program.
"These people are 60% to 70% less likely to have a heart attack," says
Evans. "We work with a high-risk group for three months, teaching them to
live a different lifestyle. But before we teach them what to do, we teach
them why they need to do it. So they know that not only is the company at
economic risk, but they're at health risk. And if they want to live a long,
healthy life instead of a short, disabled life, they need to make changes."
Toward healthy newborns
Companies are
increasingly conscious of maternal and infant health because nearly half the
work force is female, and by 2000 that figure is expected to climb to 60%.
Seventy percent of
working women were of childbearing age in 1992, amounting to 38 million
employees. For many companies, childbirth-related expenses are the single
most expensive category of health plan costs, and most of the expense is
attributable to a small number of problem births.
In a report for CIGNA Corp., researchers at Georgia State
University found that in 1990, health care associated with poor birth
outcomes cost employers and employees $5.6 billion, the equivalent of 3% of
aggregate after-tax corporate profits that year.
Many employers believe
that health care plans that focus on prevention and prenatal care, coupled
with lifestyle education and the management of high-risk pregnancies, can
help reduce childbirth-related costs. Unfortunately, the effects of such
programs are sometimes difficult to quantify. A recent article in The New
England Journal of Medicine questioned the presumed cost savings of prenatal
care plans; without disputing the value of such programs, the authors argued
that claims of specific savings were based on flawed research.
The authors' findings
were vigorously disputed by the March of Dimes Birth Defects Foundation in
White Plains, N.Y. Jennifer L. Howse, Ph.D., president of the foundation,
says that "the cumulative weight of many studies is that prenatal care saves
lives and money by reducing the number of babies born needing expensive
neonatal care." Moreover, she argues, good prenatal care not only reduces
catastrophic health costs but also reduces absenteeism, improves
productivity and morale, and enables a company to retain valued workers.
At Home Depot Corp.,
more than 26,000 of the 67,000 employees are women, and most are in their
childbearing years, says Wes LeCroy, wellness coordinator at the
Atlanta-based company. In 1992, Home Depot began a prenatal program aimed at
improving infant health and reducing claims cost. Because the company has
changed third-party administrators several times, LeCroy explains, the data
regarding maternity costs are not readily accessible. However, claims for
premature births that cost $75,000 or more amounted to $1.6 million in 1991,
the year before the program was introduced.
Home Depot's program
includes the March of dimes "Babies & You" materials as well as a risk
assessment questionnaire and high-risk case management components from
Health Risk Management (HRM) in Minneapolis. By 1993, the second year of the
effort, cases exceeding $75,000 totaled $364,000, for a decline of 77%. In
addition, pregnant employees experienced a premature birth rate of 4.1% in
1993, far below the national average of 10.8%, reports HRM.
Employees who precertify
for pregnancy care are given Home Depot's pregnancy packet, which contains
the questionnaire. HRM then evaluates survey forms for risk factors. Those
who complete prenatal classes receive a waiver of the $100 deductible for
hospital care.
Ann Downs-Pete, senior
supervisor of case management at HRM, says, "The goal of our maternity
program is to provide early identification of risk to facilitate quality
treatment and positive outcome, resulting in improved likelihood of
full-term birth and reduced costs." In the program, called Quality Birth, an
obstetrician from HRM calls the employee's physician to verify information
and introduce the program. A nurse care manager contacts the pregnant
employee at least biweekly to provide her with educational materials and
answer questions. Making sure the expectant mother understands the signs and
symptoms of premature labor is especially important, says Downs-Pete.
Healthy backs
According to a report
from the University of Washington School of Public Health, low back pain
afflicts 60% to 80% of all U.S. adults at some point in their lives. Direct
medical costs for the complaint exceeded $24 billion in 1990. At L.L. Bean Inc., the
Freeport, Maine, sporting goods company, many of the 8,000 employees on the
payroll are at risk for back injury. (Someone's got to lug all those
snowshoes, axes, and canoes!) Approximately 2,000 employees work in
warehouses and another 500 in manufacturing facilities, not to mention
office workers. "We take back care seriously," says Ted Rooney, manager of
employee health and safety.
L.L. Bean started a back
care program in the late 1980s as one part of a broad wellness program that
now includes classes in such subjects as stress management, nutrition,
self-defense, skier conditioning, massage, and yoga. For participating in
specific wellness courses, such as cholesterol reduction and blood pressure
education, employees can earn up to $100 in credit toward insurance
premiums. L.L. Bean spent $88,000 on such credits in 1993; the wellness
program for the same year cost $167,000. The privately held company does not
disclose the cost of individual prevention programs such as its back care
effort, which includes job and workplace redesign, thrice-daily stretch
breaks, ergonomic planning, and intensive intervention with workplace
physical therapy for injuries. The program also stresses weight control,
smoking, and other lifestyle characteristics.
"We've seen a 70%
decrease in the number of lost-time claims from 1989 to 1993," says Rooney.
A 1993 employee health survey showed that 56% of respondents participate in
the stretch break program, which is mandatory in manufacturing sites, most
distribution areas, and some offices. There are formal stretch breaks led by
volunteers as well as stretch break flash cards for employees in areas where
group stretches are impractical. For certain areas, such as some offices and
retail areas, workers are given a stretch break packet for individualized
stretch routines.
Even CEO Leon Gorman,
when in a warehouse during stretch break, has joined in. What happens if
management doesn't participate? "Believe me, we hear about it from the
employees," says Rooney.
"We realize that a back
is a back," he adds, "and it's influenced by on-the-job and off-the-job
characteristics and by personal characteristics. So we try to influence all
those factors to get the most leverage for our dollar." In an effort to
predict injury rates, the company is now studying back strength in the work
force over time and comparing that information to the demands and the
ergonomics of individual jobs.
Breast cancer detection
Health administrators
from SmithKline Beecham Corp. in Philadelphia performed an analysis of
mammography screening at the clinical laboratories division, with about
10,000 employees, from 1991 through mid-192. "We covered mammography and
assumed that women would have the test done. But giving people access
doesn't mean they're going to take advantage of the services. You need to go
further," says Sharon A. Wilkie, manager of corporate health and wellness of
SKB. Even though mammography
was a fully covered benefit without any deductible or co-payment, the
company found 11 women with late-stage breast cancer who had not been
getting mammograms. These cases resulted in eight deaths and more than $1
million in direct medical costs.
In response to the
discovery, the company implemented a nationwide on-site mammography
screening program for the clinical laboratories division in June 1992. By
March 1994, 798 women had been screened, revealing 67 non-cancerous
abnormalities and five cases of breast cancer. The cost of the program was
almost $53,000, but the potential saving, based on the assumption that all
cases are in an early stage, is estimated to be $450,000. "It is a
cost-effective program because people are getting preventive care and not
leaving the workplace, and because we're saving lives," says Wilkie.
Helping asthmatics
Homedco Group Inc., a
home health care service company in Fountain Valley, Calif., launched an
asthma intervention program in late 1994. Asthma, which affects nine million
to 15 million people in the United States, was responsible for more than $6
billion in total expenditures in 1990, according to the company.
Furthermore, between 1979 and 1990, the hospitalization rate of asthmatics
rose 22%, with the rate among children increasing by 56%.
Homedco's program,
designed in both adult and pediatric versions, relies on patient education,
environmental inspections, drug therapy, and information systems to assess
disease severity and monitor therapy. "The objective is to
help patients better understand and manage their disease, resulting in an
improved quality of life and reduced medical expenses," says Karen M.
Thomsen, product manager at Homedco.
In the 12-to-18-month
home program, which includes monthly home visits, the company establishes an
individual health plan for the patient. Homedco inspects the home
environment for agents that may trigger asthma attacks and creates baseline
values by having the patient blow into a peak air flow meter in order to
monitor the disease and anticipate future attacks. Thomsen says that while
the program is too new to have produced measurable results, research
suggests that intervention programs keep asthmatics out of the hospital.
Diabetes is another
condition for which disease management may prove effective. The American
Diabetes Association in Alexandria, Va., estimates that close management of
the disease could double the annual expense of treating each diabetic, now
about $1,500 to $2,000 for medication and testing. But proper management
could eliminate a substantial part of the $20 billion spent each year on
complications from diabetes.
Managing chronic disease
Disease management, a
form of case management that seeks to obtain optimal care for the patient
while reducing costs, holds promise in limiting the number of major
interventions in the treatment of chronic disease. Edward Zalta, M.D.,
chairman of CAPP Care, a managed-care company in Newport Beach, Calif.,
define disease management as "pro-active intervention in the identification,
management, and treatment of diseases so as to organize services and
products to address the total care of the patient and reduce overall costs."
One goal of disease
management is to prevent long-term complications. "The process should
include empowering patients with the knowledge and tools to maintain or
improve their condition," adds Zalta.
CAPP Care is developing
disease management programs for diabetes, asthma, peptic ulcer, migraine
headache, and benign prostate disease. They are scheduled to be implemented
in July. "We have one employer who had 220 hospital admissions last year for
diabetes, which would cost about $6,000 per admission. In a perfect world,
the diabetic should never be admitted to the hospital. The employer also had
more than 120 admissions for asthma, over 90% of which were caused by 20
patients. So we will identify the patients and the problems and empower the
patients with information to avoid the next attack."
The current stage of
development, says Zalta, is preparing hand-held computers for physicians,
loaded with clinical and patient guidelines that are integrated into other
information systems.
"Doctors are too busy to
refer to printed guidelines," says Zalta. "There are 33,000 articles
appearing in the medical literature every month. So the guidelines must be
in a format the doctors can take everywhere. As the doctors work through the
guideline, they will record what they do, giving us information with which
to analyze outcomes and monitor guideline compliance."
The computer will merge
claims information from the medical and pharmacy sides, informing the doctor
if the patient has filled his or her prescriptions, how many emergency room
and doctor visits have occurred, and if the guideline is being followed.
Zalta says he expects the hand-held computers, along with the other elements
of the disease management program, to be in use by CAPP Care physicians by
July.
Primary vs. tertiary
So what's the best
strategy for employers to pursue? Narrowly focused prevention programs may
yield the most rapid return on investment, but some experts argue that in
the long run, they may be less effective than primary preventive measures.
(Primary prevention is trying to avoid disease; secondary prevention is
trying to stop, at an early stage, the disease's progression; and tertiary
prevention is managing advanced disease.)
"Does tertiary
prevention, efforts like chronic disease management, have a bigger
short-term impact than primary prevention?" asks Paul Terry, vice president
for education at Park Nicollet Medical Foundation in Minneapolis. "If you
take the public health viewpoint, tertiary prevention is not likely to be
more effective because there're just so many more people who can benefit
from primary prevention. By changing the health habits of a very large
population just a little bit, you'll have greater net gain than you would by
changing a very small population in a more significant way."
How does Park Nicollet,
a multispecialty group practice with award-winning prevention programs,
approach the problem? The organization actively engages in primary,
secondary, and tertiary prevention. Says Terry: "We're hedging our bets."
The group has found the employers value every prevention strategy that is
cost-effective.
Author:
Anonymous Source: Business & Health v13n3 (Suppl. A) (1995):
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